Anxiety disorders

Question 1

Name the curve that describes the effect of anxiety on performance

Answer 1

Yerkes-Dodson Law bell curve

Question 2

List the psychological theory behind anxiety to a threat

Answer 2

• Reduced perception of ability to cope with threat
• Reduced perception of ability to cope with the symptoms of arousal
• Tendency to react to stress with arousal response

Question 3

List the ICD-10 classifications of neurotic and stress-related disorders

Answer 3

Acute stress disorders:
- Acute stress reaction
- PTSD (post-traumatic stress disorder
- Adjustment disorder

Phobic anxiety disorders:
- Agoraphobia (with or without panic disorder)
- Social phobia
- Specific phobia

Other anxiety disorders:
- Panic disorder
- GAD (generalised anxiety disorder)
- Mixed anxiety and depressive disorder

Obsessive–compulsive disorder

Question 4

State the 1 year prevalence of anxiety disorders

Answer 4

14%

Question 5

Outline the features of generalised anxiety disorder (GAD), according to ICD-10 classification

Answer 5

• Anxiety that is generalised and persistent
• ‘Free floating’ = does not strongly predominate in any particular environmental circumstances

Worrying most days about most things, for a period of 6 months

Question 6

List some psychological and physical symptoms of generalised anxiety disorder (GAD)

Answer 6

Psychological:
- Anxious thoughts
- Fearful anticipation
- Poor concentration
- Irritability
- Sensitivity
- Avoidance behaviour

Physical:
- Sleep disturbance
- Weight loss
GI - dry mouth, diarrhoea
Respiratory - tachypnoea, tight chest
CVS - tachycardia
Urinary - frequent urination
Neuromuscular - headache, tingling, tremor

Question 7

State some proposed risk factors for development of anxiety disorders

Answer 7

Often an initial precipitant
- Genetic
- Upbringing
- Personality type e.g. more likely to worry or due to personality disorder

Often maintained by stressful life events or patterns of thinking

Question 8

State the 3 factors involved in the CBT model

Answer 8

1. Thoughts
2. Feelings
3. Behaviours

Question 9

List some factors to consider when prescribing SSRIs for anxiety

Answer 9

• Short term increase in anxiety and suicide
• Review within a month, then 3 monthly thereafter
• Drug interactions

Question 10

List some potential drug interactions for SSRIs

Answer 10

• Cough medication (drowsiness)
• NSAIDs (bleed risk)
• Alcohol (increased potency of alcohol)
• Cocaine (serotonin syndrome)

Question 11

Outline the management of generalised anxiety disorder (GAD)

Answer 11

Stepwise treatment plan, escalating as appropriate

Step 1: Education (lifestyle measures) + active monitoring

Step 2: Low intensity psychological interventions

Step 3: High intensity psychological intervention
- CBT
- First line medications: antidepressants SSRIs / SNRIs
- Avoid Benzodiazepines (risk of addiction)
(continue treatment after remission for at least 6 months to ensure remission)

Step 4: highly specialist treatment e.g. high intensity psychological intervention, drug treatment, MDT involvement and crisis team

Question 12

Outline agoraphobia (features from ICD-10 classification) and how it differs from social phobia

Answer 12

Fears of:
- Leaving home
- Entering shops / crowds / public places
- Travelling alone in trains, buses or planes
Co-morbid panic disorder, depressive symptoms, obsessional symptoms and social phobias often

Different from social phobia, fine with social situations, as long as at home

Question 13

Briefly state what a social phobia is (features from ICD-10 classification)

Answer 13

• Fear of scrutiny by other people, leading to avoidance of social situations
• General anxiety symptoms present
• Symptoms may progress to panic attack

Question 14

Outline the management of phobias (agoraphobia, social phobia, specific phobia)

Answer 14

• Self-help techniques
• CBT and other talking therapies
• SSRIs

Question 15

Briefly state what a panic disorder is, based on ICD-10 classification

Answer 15

• Recurrent attacks of severe anxiety (panic)
• Not restricted to any particular situation / circumstances (unpredictable)
• Secondary fear of dying, losing control, or going mad

Question 16

Briefly state how panic disorder is managed

Answer 16

• Self-help methods, support groups and exercise
• CBT
• SSRIs / SNRI or TCA (DON’T prescribe benzodiazepines)

Question 17

List general features of PTSD, according to ICD-10 classification (triad plus other features)

Answer 17

Delayed response to an event of exceptionally threatening nature

3 key features:
- Re-experiencing event (flashbacks or nightmares)
- Hyperarousal
- Avoidance behaviours

Other features:
- Anxiety and depression (commonly associated)
- Insomnia
- Anhedonia
- Numbness
- Detachment from others

Symptoms last for > 4 weeks, (generally > 6 months)

The course is fluctuating but recovery can be expected in the majority of cases

Question 18

Outline the management for post-traumatic stress disorder (PTSD)

Answer 18

Biological:
- Consider SSRIs if patient preference (avoid Benzodiazepines) e.g. Paroxetine or Mirtazepine
- Consider antipsychotics e.g. Risperidone, if severe and disabling

Psychological:
- Individual trauma-focused CBT interventions
- Consider eye-movement desensitisation and reprocessing (EMDR) if non-combat trauma

Social:
- Watchful waiting (if < 4 weeks)
- Support groups

Question 19

Outline the features of obsessive compulsive disorder (OCD), according to ICD-10 classification

Answer 19

• Recurrent obsessional thoughts
• Compulsive acts
• Distressing thoughts (egodystonic) and try to resist them
• Recognised as patient’s own thoughts

Question 20

Suggest some factors which may contribute to OCD

Answer 20

Precipitated by life event, maintained by avoidance or rituals
- Genetics
- Early experiences
- Organic e.g. PANDA syndrome

Question 21

List 3 key features of PTSD

Answer 21

• Re-experiencing event (flashbacks or nightmares)
• Hyperarousal
• Avoidance behaviours

Question 22

Briefly state the management options for patients with obsessive compulsive disorder (OCD)

Answer 22

• Psychoeducation
• Exposure and response therapy
• CBT

Moderate-severe or treatment resistant:
- Antidepressants (SSRIs)
- More intensive CBT

Question 23

Briefly outline somatisation disorder (what it is and how it presents)

Answer 23

‘Briquet disorder’
- Multiple, recurrent and frequently changing physical symptoms
- Present for at least 2 years
- Symptoms may be referred to any system / part of body

• Often complicated history of contact with both primary and specialist services

Question 24

Briefly outline hypochondriacal disorder (what it is and how it presents)

Answer 24

• Persistent preoccupation with the possibility of having one or more serious and progressive physical disorders
• ‘Normal’ sensations often interpreted by patients as abnormal
• Attention is usually focused upon 1 or 2 organs / systems of the body

Question 25

Briefly outline medically unexplained symptoms and how they are managed

Answer 25

- Persistent symptoms for which examinations fail to reveal sufficient explanatory structural or other specified pathology - Often presents as: generalised pain, fatigue or altered organ systems (e.g. stomach ache, breathlessness) - Usually present for > 3 months, with impaired functioning. Management: - Reassurance and careful communication - Screen for underlying mental health problems e.g. anxiety - Psychosocial support and therapies such as CBT Extensive investigations are unlikely to add to the diagnosis

Question 26

Briefly outline somatoform disorder (what it is and how it presents)

Answer 26

- Physical symptoms that cannot be explained by a medical condition, drug or other mental health disorder - Unconscious process - Common presenting symptoms: GI symptoms and abdominal pain, fatigue, weakness and MSK symptoms

Question 27

Briefly outline conversion disorder (what it is and how it presents)

Answer 27

- Psychiatric condition - Presentation of neurological symptoms without any underlying neurological cause e.g. paralysis, pseudo-seizures, sensory changes - Unintentional process, symptoms are very much "real" to the patient - Linked to emotional stress

Question 28

Outline the difference between Munchausen's syndrome and malingering

Answer 28

Munchausen's syndrome - Patients intentionally fake signs and symptoms (e.g. adding blood to urine and complaining of pain) - Aim is to gain attention and play "the patient role" Malingering - Patients intentionally fake or induce illness for secondary gain e.g. drug seeking Difference is that both conditions have a different aim to why they are deliberately faking illness

Question 29

Outline the features of adjustment disorder, according to ICD-10 classification

Answer 29

- Subjective distress and emotional disturbance, in response to a significant life change or a stressful life event - Usually to level of interfering with social functioning and performance - Persists for no longer than 6 months after stressor

Question 30

State how a adjustment disorder can present and give some examples of some potential causes of adjustment disorders

Answer 30

Manifestations vary and include: - depressed mood - anxiety or worry - feeling of inability to cope, plan ahead, or continue May struggle to carry out ADLs Examples: - Bereavement - Separation - Migration / refugee - Going to school - Becoming a parent - Failure to attain personal goal - Retirement Key difference: assumed that the condition would not have arisen without the stressor

Question 31

Suggest the difference between adjustment disorder and acute stress disorder

Answer 31

In adjustment disorders, the stressful event (losing a job, relationship ending) is typically less traumatic than an event that causes acute stress disorder (sexual assault, mass shooting)

Question 32

Suggest some management steps for adjustment disorders

Answer 32

Formal treatment is often not needed Support: - Help managing the stressful situation e.g. if bullied, contact the school / work - Psychoeducation - CBT or psychodynamic therapy